EMERGENCY REPORT

RSO Prof. Dr. R. Soeharso Solo

Sunday, Oktober 16th, 2016
Team :
dr. Adli
dr. Arief
dr. Alifia
dr. Hastomo
Consultant : dr. Rieva Ermawan, Sp.OT (K)

Patients Admission

Inpatient
No

Identity

Diagnosis

Plan

M.Fikri
18 y.o
MR 296252

Closed fracture of right

subtrochanter femur,
comminutive, Fielding 1

ORIF

Puswirarto
41 y.o
296255

CF of left Tibia Segmental

CF of left Fibula middle third

ORIF

Dwi Setiawan
26 y.o
296255

CF of left interthrochanter
femur Boyd Griffn type II

ORIF

Ngatinah
65 y.o
296254

CF of right proximal humeri

neer 3 part
CF of based metatarsal digiti 1
right hand
CF of left Tibia Fibula middle

ORIF

Patients Admission

Outpatient
No

Identity

Diagnosis

Plan

Fathan
47 y.o
MR 296245

Acute Low Back Pain

Oral Analgetic

Orlin
13 y.o
MR 205447

Left Ankle Sprain

Boot Slab
Oral Analgetic

Azzam
7 y.o
MR 185951

Observation of Febris Day 3

Laboratory
Analgetic/Antipire
tic

Sri Atmini
70 y.o
MR 296248

Contusio musculorum of right

foot

Bandage
Oral Analgetic

Patients Admission

Outpatient
No

Identity

Diagnosis

Plan

Firda
13 y.o
MR 296250

Right Sprain Ankle

Boot cast
Oral Analgetic

Okie
41 y.o
MR 296251

Contusio musculorum of right

knee

Bandage
Oral Analgetic

1st Patient

IDENTITY

Name
: M. Fikri
Sex
: Male
Age
: 18 y.o
Occupation
: Student
Medical Record : 296252
Ward
: PK/III

Primary Survey
Male, 18 years old, came to the emergency department with
chief complaint pain over his right tight after MVA
A: Clear
B: Spontaneous, Thoraco-abdominal respiration, RR: 20x/m
C: HR: 82 x/m, BP: 134/80 mmHg
D: GCS E4V5M6, isochoric pupil (3 mm/3 mm)
E: T : 36,5 C, lesion (+) look at physical examination

History Taking
Chief Complaint : Pain over right thight
History of illness :

14 hours prior to admission, the patient involved

MVA. He crushed with another motorcycle from
opposite direction and hit his thight directly. After
that accident, he felt sharp pain on her right thigh
that aggravated by movement and unable to bear
his body weight. There was no pain in other parts
of the body.
Past illness :

There is no history of deformity and pain before

the accident.

Secondary Survey
Head
: no abnormality
Neck
: no abnormality
Eyes
: no abnormality
Nose
: no abnormality
Ears
: no abnormality
Mouth : no abnormality
Chest : no abnormality
Back
: no abnormality
Abdominal : no abnormality
Extremities : Lesion (+) look at physical examination

Physical Examination
Right thight region
L : Skin intact, swelling (+), bruishing (+), deformity
(+) shortening, exorotation
F : NVD (-), Tenderness on the proximal and middle
third of thight, LLD : 2 cm
M : ROM hip and knee limited due to pain, ROM ankle
and toes full
D

Anatomical
length

40

42

True length

60

62

Apparent
length

80

82

Clinical Appearance

1st Assessment
Closed fracture of the right femur
DD: CF of right subtrochanter femur
CF of right shaft femur

1 Plan
st

Immobilization
Analgetic injection
X ray examination
Laboratory examination

X-ray

2nd Assessment
Closed fracture of right subtrochanter
femur, comminutive, Fielding 1
(AO 31.A2)
ISS score: 9
VAS: 4-5

nd

Plan

Initial treatment:
Immobilization with skin traction
Definitive treatment:
ORIF

2nd Patient

IDENTITY

Name
: Puswiratmo
Sex
: Male
Age
: 41 y.o
Medical Record : 296253
Occupation
: Stonemason
Ward
: PK/III

Primary Survey
Male 41 y.o, came to emergency room with chief complain

pain on the left lower leg after MVA

A: Clear, stable c-spine
B: Spontaneous, thoracoabdominally, RR: 18 x/m
C: HR: 88 x/m, BP : 130 / 70mmHg
D: GCS E4V5M6, isochoric pupil (3 mm/3 mm)
E: T : 36,2 C, lesion (+) at left lower leg

History taking
Chief Complaint :
Pain on the left lower leg
History of Present Illness :
5 hours prior to admission, the patient
involved in MVA. He was strucked a cat.
After that, she felt pain on the left lower
leg that aggravated by movement. There is
no pain in other part of the body before
accident.
History of past illness:

Secondary Survey
Head
: no abnormality
Eyes
: no abnormality
Nose
: no abnormality
Ears
: no abnormality
Mouth : no abnormality
Chest : no abnormality
Abdominal : no abnormality
Back
: no abnormality
Extremities : Lesion (+) look at physical examination

Physical Examination
Left lower leg region :
L : Skin intact, swelling (+), unclear deformity
F : NVD (-), Tenderness (+) over lower leg region
M : ROM knee and ankle hard to evaluate due to pain
ROM Hip was normal

Clinical Picture

1st Assesment
Closed fracture of the left shaft tibia
fibula

1 Plan
st

Analgetic Injection
Immobilization
X-Ray examination
Laboratory examination

X ray

nd

Assesment

Closed fracture of left shaft tibia,

segmental type
Closed fracture of left fibula, middle
third
(AO 42.C2)
VAS: 4-5
ISS : 9

2
ORIF tibia

nd

plan

3rd Patient

IDENTITY

Name
: Dwi Setiawan
Sex
: Male
Age
: 26 y.o
Medical Record : 296255
Occupation
: employee
Ward
: PK/II

Primary Survey
Male 26 y.o came to the emergency department with a chief
complain pain on her left hip after MVA
A: Clear, stable c-spine
B: Spontaneous, thoracoabdominally, RR: 20 x/m
C: HR: 87 x/m, BP : 126/77 mmHg
D: GCS E4V5M6, isochoric pupil (3 mm/3 mm)
E: T : 36,5 C, lesion (+) look at physical examination

History Taking
Chief Complaint :
Pain on the left hip
Present illness :
18 hours prior to admission, patient was involve a
MVA. He fell from motorcycle to te left side and his
left hip hit the ground first. She felt sharp pain on
the left hip that aggravated by movement. She was
unable to bear his body weight. No pain in other
site of the body.
Past illness :
There is no history of pain, trauma, or deformity
before the accident.

Secondary Survey
Head
: no abnormality
Neck
: no abnormality
Eyes
: no abnormality
Nose
: no abnormality
Ears
: no abnormality
Mouth : no abnormality
Chest : no abnormality
Abdominal : no abnormality
Back
: no abnormality
Extremities : Lesion (+) look at physical examination

Physical Examination
Left Hip Region
L : skin intact, swelling, deformity (+)
exorotation, shortening
F : NVD (-), Tenderness (+) proximal femur,
Bryant triangle not equal to opposite, LLD
2 cm
M: ROM hip is limited due to pain. ROM
knee, ankle, toes normal

Clinical picture

1st Assessment
CF of left proximal femur
DD : CF of left intertrochanter femur
CF of left collum femur

1st Plan:

Immobilization
Analgetic injection
X ray examination
Laboratory examination

X Ray

2nd Assesment
CF of left Intertrochanter femur, BG II
(AO 31-A2)
ISS: score 9
VAS : 5-6

nd

Plan

Definitive treatment:
ORIF

4th Patient

IDENTITY

Name
: Ngatinah
Sex
: Female
Age
: 60 y.o
Medical Record : 296254
Occupation
:Ward
: PS/III

Primary Survey
Male 60 y.o, came to emergency room with chief complain

pain on the left lower leg after MVA

A: Clear, stable c-spine
B: Spontaneous, thoracoabdominally, RR: 18 x/m
C: HR: 88 x/m, BP : 150/85 mmHg
D: GCS E4V5M6, isochoric pupil (3 mm/3 mm)
E: T : 36,2 C, lesion (+) at left lower leg

History taking
Chief Complaint :
Pain on the left lower leg
History of Present Illness :
3 days prior to admission, patient was strucked by
motorcycle. Motorcycle hit her left lower leg. After that,
she fell of to the right side and felt sharp pain on the
left lower leg that aggravated by movement. Patient
was unable to bear her body weight. Theres also sharp
pain on the right shoulder and base of 1st finger that
aggravated by movement.
History of past illness:
There is no history of pain, trauma, or deformity before
the accident.

Secondary Survey
Head
: no abnormality
Eyes
: no abnormality
Nose
: no abnormality
Ears
: no abnormality
Mouth : no abnormality
Chest : no abnormality
Abdominal : no abnormality
Back
: no abnormality
Extremities : Lesion (+) look at physical examination

Physical Examination
Left lower leg region
L : Skin intact, swelling (+), bruishing (+) deformity
(+) exorotation
F : NVD (-), Tenderness (+) over lower leg region
M : ROM knee and ankle hard to evaluate due to pain
ROM Hip was normal
Right shoulder Region
L : Skin intact, bruising (+), swelling (+), deformity
unclear
F : NVD (-), Tenderness (+) proximal humerus
M: ROM finger and wrist normal, ROM elbow and
shoulder cant evaluate by movement

Clinical Picture

Clinical Picture

1st Assesment
Closed fracture of the right proximal
humerus
Closed fracture of the left tibia and
fibula
Injury around right hand region

1 Plan
st

Analgetic Injection
Immobilization
X-Ray examination
Laboratory examination

X ray

X ray

nd

Assesment

Closed fracture of left shaft tibia fibula

distal third
Closed fracture of right proximal
humerus, neer 2 part
Closed fracture of base metacarpal of
right hand (Bennet Fracture)

VAS: 3-4
ISS : 9

2
ORIF

nd

plan

Thank You